After Temporomandibular Joint Surgery

Patients who have had temporomandibular joint arthroscopy may go on to require temporomandibular joint surgery, or alternatively patients with conditions too severe for arthroscopy may benefit from open joint surgery. This often involves an arthroplasty, which is effectively a repair of the joint. Frequently a graft of cartilage will be harvested from the helix of the ear on the same side as your jaw joint surgery to facilitate the reconstruction of the joint. Some patients may undergo a total joint replacement which usually involves the removal of a badly damaged joint and reconstruction using a costochondral (rib) graft. The information below is a guide for patients to follow on discharge from hospital:

1. HYGIENE/CARE OF WOUNDS.

Dressings are usually applied to the wounds in the operating theatre. These can be removed after 24 hours and it is possible to shower providing the wounds are not placed DIRECTLY under the shower head. The wounds can become a little damp but should be carefully dried off with a clean towel following your shower. It is also permissible to wash your hair, but once again the wounds should not get soaking wet.

For patients undergoing total joint replacements, the jaws are immobilised using arch bars and intermaxillary fixation during the surgery. The arch bars are left in place following the surgery and these need to be kept as clean as possible with regular toothbrushing and Savacol mouthwashes; a Broxojet may also be supplied by the ward. You should commence your mouthwashes and toothbrushing the day AFTER surgery and you should aim to use at least 5-6 mouthwashes per day.

2. DRESSINGS.

The dressings applied in the operating theatre can be removed after 24 hours. Frequently a small drain will be inserted into the surgical site and this is removed at the same time as the dressing. For patients who have undergone an auricular cartilage graft to repair the temporomandibular joint there is frequently a dressing sutured into the ear to maintain the shape of the ear and UNDER NO CIRCUMSTANCES SHOULD THIS BE REMOVED as to do so would run the risk of spoiling the shape of the ear long-term. It is always removed by Dr. Bowler at the one week review appointment.

3. SWELLING AND BRUISING.

The surgical site following temporomandibular joint surgery will often swell. Generally, swelling takes 2-3 days to reach its maximum and then at least 10 days to slowly settle. On occasions some bruising may be seen in the surgical site and this may take up to 14 days to disappear.

4. NUMBNESS.

Local anaesthetic injections are used at the time of surgery for pain control post-operatively. Your surgical site will be numb for 6-8 hours following surgery and this will gradually resolve. On occasions sensory nerves in the area of surgery may be stretched or bruised during the surgery and you may experience prolonged numbness that can take several weeks or even several months to wear off. On rare occasions there may be small permanent patches of localised numbness.

5. BLEEDING.

It is uncommon for a surgical site to bleed post-operatively however if there is some bleeding, rest quietly with your head elevated and apply pressure to the wound. If bleeding persists beyond 30 minutes please contact Dr. Bowler or the hospital in which you were treated. You may notice some dry crusting of blood in the external auditory meatus (ear canal). This is quite normal and should not be “picked at”. The crusted blood will gradually peel away with time.

6. DIET.

It is important to restrict your diet to VERY SOFT FOODS for the first three days. Patients undergoing arthroplasty surgery can build up their diet to a reasonable consistency over 2-3 weeks. Patients undergoing jaw joint replacement surgery need to be aware the replacement joint is screwed to the side of the jaw and full bony union will not be achieved for at least six weeks. In view of this jaw joint replacement patients require a TOTALLY BLENDED DIET FOR SIX WEEKS. Further information on diet can be obtained from the hospital dietitian.

It is important to slowly exercise your jaw following temporomandibular joint surgery but the exercises should be relatively gentle and in the case of joint replacement patient chewing is NOT AN OPTION for exercise.

7. SMOKING.

It is highly desirable that you do not smoke for at least 2-3 weeks following the surgery and IF BONE GRAFTING HAS BEEN CARRIED OUT YOU SHOULD NOT SMOKE AT ALL until advised by Dr. Bowler. Please be aware that smoking has a systemic effect and a history of smoking can jeopardize the overall success of your surgery. In some cases you may be asked to cease smoking completely for three months before surgery can be considered.

8. SPECIAL ASPECTS.

It is not uncommon for the occlusion or “bite” to feel slightly “out”. This will gradually settle over about ten days and relates to swelling within the joint. For patients who have undergone joint replacement surgery it may be necessary for elastics to be used to hold the jaws together for a few days to help the bite settle. You will be supplied with small cutter and clips to help insert and remove the elastics.

Patients who have had a rib harvested for the purposes of joint replacement will be issued with a “Triflo” device which should be used at least six times per day with the aim of raising all three balls. Patients who are smokers should consider their surgery an opportunity to cease smoking completely!

Harvesting of a rib will generally prevent you from moving quickly and you will require slow steady steps to gradually become rehabilitated. It is possible to do some gentle exercises but this should not commence until the drain is removed approximately 24 hours post-op. Some patients may require a walking frame or stick and you should expect your walking and your ability to lift objects to take 10-14 days to return to normal.

Patients may occasionally notice some deafness in the ear on the operated side. This is usually related to some fluid in the ear canal and also some swelling following the surgery as the surgical incision involves dissection down the ear canal. This deafness will gradually subside over 10-14 days and if it persists Dr. Bowler will check your ear with an auroscope and may recommend an assessment from an ear, nose and throat surgeon.

9. POST-OPERATIVE MEDICATIONS AND SUPPLIES ETC.

You will be provided with the following on discharge:

a) A course of antibiotics.
You will have been given intravenous antibiotics in the operating theatre and possibly on the ward. A prescription for your oral antibiotics will be available for you to take home or alternatively the ward may have the prescription filled for you before discharge. IT IS ESSENTIAL YOU COMPLETE ALL OF THE ANTIBIOTICS as indicated on the label.

b) Analgesics.
These are also prescribed and the prescription will be available for you to take home or, as with the antibiotics, the ward may have the prescription filled for you before discharge. Generally “middle of the range” analgesics are satisfactory for pain control following T.M.J. surgery.

c) Savacol mouthwash.
Where surgery has been performed in your mouth or arch bars have been inserted, a bottle of Savacol mouthwash will be supplied for you to take home. Please use this diluted 1 capful in a glass of warm to hot water and the mouthwash should be used 5-6 times per day, particularly at night before bed. You should start your mouthwashes the day AFTER surgery. You may need to purchase another bottle of mouthwash, depending on the progress of your wounds. A “Broxojet” may also be supplied by the ward.

d) Steroid ointment (Sigmacort – large tube).
A tube of steroid ointment will be provided for you to take home. A thin smear of ointment should be placed on the lips once or twice a day, particularly in the corners of the lips where these may have been stretched, and this can be continued for approximately a week post-operatively. The steroid ointment will assist with healing of the lips.

e) Oral hygiene/Broxojet.
Frequently patients are provided with a Broxojet irrigating device to assist with cleanliness particularly where arch bars are left on the teeth.

f) Chloromycetin ointment (small tube).
You will also receive a tube of antibiotic ointment (Chloromycetin ointment) to apply as a thin smear twice a day to any facial incisions. This must not be confused with the tube of steroid ointment used for the lips.

10. FOLLOW-UP CARE.

It is important that all patients are seen for follow-up and generally an appointment will have been made for you to attend Dr. Bowler’s rooms either the day you are discharged or shortly thereafter. Sutures are frequently a combination of resorbable (dissolvable) and non-resorbable (removable) and Dr. Bowler will advise you when these need to be removed. Suture removal intraorally is usually very simple as the sutures stay wet and therefore become easy to remove. If you do not have an appointment please telephone the practice on 4942 1211 to make a post-operative appointment.

11. EMERGENCIES.

If you have any concerns following your surgery please do not hesitate to contact the hospital in which you were treated. Dr. Bowler can be reached through the hospitals and is available most times. If for some reason this is not possible there is a 24 hour oral and maxillofacial surgery service available through the John Hunter Hospital Casualty Department.